The combination of morphine with local anaesthetic in rhinoplasty - no evidence of a peripheral morphine effect

Background: The recognition of a peripheral opioid action has prompted a number of clinical reports demonstrating a prolonged analgesic effect of peripheral opiate. As most studies have used a model of intraarticular instillation of narcotic we examined direct morphine infiltration of the surgical site in a unique clinical model. Methods: Sixty patients undergoing primary rhinoplasty were entered into this prospective, randomized, double-blind study. Patients received a standard protocol of premedication, intravenous sedation, and nasal block. Two 2 ml syringes containing saline or morphine 3 mg in saline were provided for IM injection and for addition to the local anesthetic (IW, intrawound): Group I (control) - saline IW, saline IM; Group II -morphine IW, saline IM; Group III - saline IW, morphine IM. Intraoperative assessments included need for further sedation, need for further local anesthetic, and degree of bleeding. Recovery room analgesic requirements, pain scores, and recall of intraoperative pain were recorded prior to discharge. Followup phone calls at 24 hours recorded home pain scores and analgesic use during the first postoperative day. Results: Significantly more patients in Group II (9/20) required supplemental local anesthetic intraoperatively compared to Group I (2/20) and Group III (0/20). Significantly more patients in Group II (6/20) recalled their surgical experience as painful compared to Group I (1/20) and Group III (1/20). Group II patients also evidenced significantly more operative bleeding. There were no differences in postoperative pain scores, but Group I patients required analgesic in the recovery room significantly more than in Groups II and III (85% vs 45% and 50%, respectively). There were no differences between groups in analgesic consumption at home. Conclusions: The results of this study indicate that the preoperative injection of intrawound morphine in combination with the local anesthetic both promotes bleeding and has an early pain-enhancing effect while providing no late analgesic benefit beyond that of IM morphine.